Accreditation Reg Program Mgr

GENERAL SUMMARY: Responsible for overall accountability for assigned facility accreditation and regulatory requirements including active involvement with all survey activity. Leads facility and associated on and off-campus sites activities to achieve a constant state of survey readiness. Develops ongoing education and monitoring of all departments in support of regulatory compliance. Attends appropriate meetings for dissemination of information and consultative input. Serves as assigned on quality committees and participates, chairs and oversees performance improvement activities within the accreditation and regulatory arenas. Assists the department administration in managing system accreditation and survey activities. Reports directly to the System Director of Accreditation and Regulatory Survey Preparation.




  1. Provide direction and oversight for regulatory and accreditation compliance including TJC, State and Federal Agencies;
  2. Develop Systems to ensure continual organizational readiness;
  3. Functions as a resource and educator to support management, medical and hospital staff on accreditation and other applicable regulatory requirements applicable to assigned facility;
  4. Oversees within scope of accountability the site TJC database and implements data input for the application process and monitors the data input for citation clearance. Collaborates with applicable PECOS team members to ensure TJC and PECOS/855 filings are consistent;
  5. Participates and or coordinates in all unannounced TJC/CMS surveys including MOCK surveys as member of the corporate team and participates in monthly focused checks as required or determined by the System Director. Designs, implements and takes leadership as directed of the command center during any survey activity;
  6. Assists sites in the development and implementation of plans to achieve and maintain standards compliance. Serves as a resource for departmental compliance plans sections related to TJC and regulatory requirements.
  7. Routinely monitors corrective measures to ensure ongoing compliance
  8. Researches and analyzes federal and state laws and regulations, and sub regulatory guidance that impact the assigned BH site as well as provide updates to appropriate groups and leaders;
  9. Assist BH Leaders with implementation of responsive measures to regulatory changes to better ensure BH Compliance;
  10. Participates in interdisciplinary teams in resolving compliance issues. Will be expected to promptly respond to questions affecting BH’s compliance with applicable laws, regulations, and/or BH policies in coordination with the Compliance Leadership Team;
  11. Serves as an active member of site-specific TJC/Regulatory teams and directs and educates the principles of the team in standard compliance, action plan development, monitors and sustainment of survey readiness. Integrates applicable TJC, federal and state statutes, regulations and rules.
  12. Participates on site and system level committees that assist in supporting TJC and survey readiness including, without limitation, quality, leadership, environmental safety, clinical safety, medical staff, and other teams as appropriate;
  13. Develops, conducts and monitors weekly rounding of facility units and departments and develops tracking mechanism to assure compliance;
  14. Maintains and develops expertise on TJC requirements and regulatory standards and applicable Medicare conditions of participation;
  15. Conducts self in a professional manner demonstrating excellent leadership.
  16. Develops and participates in facility on and off-campus sites for all in support of the above;
  17. Assists in developing and updating policies and procedures as they relate to accreditation and regulatory requirements at both the facility and System level;
  18. Assist departments as requested in other regulatory activities such as, but not limited to, certification surveys, nuclear regulatory commission surveys, health department surveys and College of American Pathology surveys;
  19. Assist the System Director in management of accreditation program as assigned; and
  20. Manages all databases required.






  • Minimum educational requirement is at the associate degree level. Experience will be considered in lieu of the associate’s degree. Persons with higher degrees (bachelor or master) in either nursing or business are preferred.
  • 1-3 years healthcare regulatory experience and/or management experience is preferred.



Other Qualifications:

  • Proven leadership ability; demonstrated skills related to management, analysis, quality improvement, regulatory requirements.
  • Ability to think strategically and develop innovative solutions.
  • Excellent oral, written, and interpersonal skills.
  • Ability to lead complex teams and to facilitate progressive change.